A home health nurse is assessing a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?

Reinforce the importance of daily weights.

Call the health care provider for further instructions.

Document the findings and continue with the visit.

Ensure the client has been taking their prescribed diuretic.

Answer and Explanation

The Correct Answer is D

A. Reinforce the importance of daily weights. While reinforcing the importance of daily weights is crucial for managing heart failure, it does not address the immediate concern of the patient's weight gain and edema. The nurse needs to take a more direct action to manage the patient's current condition.

B. Call the health care provider for further instructions. Calling the health care provider is a reasonable step, but it may delay immediate intervention that the nurse can perform. Ensuring the patient is taking their prescribed diuretic can provide more immediate relief from fluid retention.

C. Document the findings and continue with the visit. Documenting the findings is necessary for accurate medical records, but it does not address the urgent need to manage the patient's symptoms. Immediate action is required to prevent further complications.

D. Ensure the client has been taking their prescribed diuretic. Ensuring the patient has been taking their prescribed diuretic is the most appropriate immediate action. Diuretics help reduce fluid buildup, which can alleviate the weight gain and edema, providing quick relief and preventing further complications.

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Correct Answer is C

Explanation

A. Secondary prevention focuses on early detection and intervention to prevent further harm or complications. Tube feeding for a special needs student is not aimed at preventing the initial onset of a condition or injury.
B. Quaternary prevention focuses on avoiding unnecessary medical interventions and reducing the risk of over-medicalization. Tube feeding for a special needs student is a necessary medical intervention.
C. Tertiary prevention focuses on managing and treating existing conditions to prevent further complications or disability. Helping a special needs student with tube feeding is aimed at managing their existing condition (inability to eat orally) to prevent malnutrition or other complications.
D. Primary prevention focuses on preventing the initial onset of a condition or injury. Tube feeding for a special needs student is not aimed at preventing the initial onset of their inability to eat orally.

A. They are depressed over their current life situation. B. They compulsively act on the urge to continue internet gaming and gambling even though they suffered negative consequences. C. They do not care that they lost their job and their partner. D. They filed for bankruptcy because of their debts and job loss.

Correct Answer is B

Explanation

A. While the client may experience depression as a result of their situation, this does not specifically relate to their addiction to internet gaming and gambling.
B. This manifestation is characteristic of non-substance addictions, such as gambling disorder and internet gaming disorder. Despite experiencing negative consequences, the client continues to engage in the addictive behavior
C. This statement may be true, but it does not specifically relate to the client's addiction to internet gaming and gambling.
D. Filing for bankruptcy due to debts and job loss is a consequence of the client's addiction, but it does not specifically relate to their addiction to internet gaming and gambling.

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A home health nurse is assessing a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A school nurse is helping a special needs student with tube feeding during the lunch hour. Which of the following levels of prevention does this fall under?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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